Y O U A N D Y O U R FA M I LY

Patient’s full name:

Address:

Title: Mr Mrs Ms Dr Miss OtherPost code:

Date of birth:Phone(H):Mobile:

Email address:

Occupation:

Business address:

Post code:Phone:

Hobbies and interest

Emergency contact:Relationship to patient:

Address:

Post code:Phone:

Name of person(s) responsible for fees:

Address: (Complete only if different to above)

Post codePhone:

Email Address:

Do you have dental insurance? Yes No If yes, which fund?

How did you find out about us? Family dentist Yellow pages  Friend ______Relative Website Other

Y O U R D E N TA L H E A LT H

What is your dentist’s name?

Address:

Post code:Phone:

When was your last dental examination?

Have you ever had any injuries to the face, mouth or teeth?...... Yes No

Have you ever sucked a thumb or fingers? Until what age?...... Yes No

Do you have any speech problems?...... Yes No

Do you have any jaw problems (e.g clicking, locking)?...... Yes No

Have you ever had any serious problems with dental treatment?...... YesNo

Does anyone else in the family have an orthodontic problem?...... Yes No

Has anyone else in the family had orthodontic treatment?...... Yes No

What is your main concern regarding your teeth?

Y O U R G E N E R A L H E A LT H

What is your doctor’s name?

Address:

Post code: Phone:

Have you ever had any of the following:

High blood pressure...... Yes  No

Heart problems...... Yes  No

Asthma or breathing problems...... Yes  No

Rheumatic fever...... Yes  No

Autism Spectrum Disorder...... Yes  No

Tuberculosis...... Yes  No

Stomach or bowel problems...... Yes  No

Kidney disease...... Yes  No

Diabetes...... Yes  No

Thyroid problems...... Yes  No

Excessive bleeding or blood disorder...... Yes  No

Epilepsy...... Yes  No

Hepatitis...... Yes  No

AIDS/HIV...... Yes  No

Joint problems or arthritis...... Yes  No

List any other previous illnesses

Are you currently taking any tablets or medicines?...... Yes  No

If yes, please list

Have you ever stayed in hospital, had an operation, or a general anaesthetic?...... Yes  No

If yes, please provide details

Do you have an artificial hip, heart valve or other prosthetic implant?...... Yes  No

Are you allergic to any medicines or products (e.g. penicillin, latex)?...... Yes  No

If yes, please list

Females, are you pregnant?...... Yes  No

Do you smoke? Yes  No How many? /day Would you like to stop? Yes  No

I have completed this questionnaire to the best of my knowledge, and understand that failure to make a full disclosure may place meat undue medical risk. I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to otherdental practitioners to aid them in my treatment and I consent to this. I also give my permission for the practice to use the abovecontact details to send me appointment and check-up reminders.

Signature:

Please print name:Date:

Pure OrthodonticsABN 56102 231 256

Suite 1B, Level 2, 12 Hall Street, Moonee Ponds, Victoria, 3039 I phone 9370 3155 I fax 9370 3051 I email